Sepsis I Know It When I See It September 15, 2017 Matthew Exline, MD MPH Medical Director, Medical ICU What is sepsis? I shall not today attempt further to define the kinds of material [b]ut I know it when I see it Justice Potter Stewart RECOGNITION 1
Objectives Identify patients at risk for sepsis Identify common presentations of sepsis Understand the new definition of sepsis in context of previous sepsis work 3 Objectives What is Sepsis? (Sepsis 3.0 Definition) What is qsofa? What is SEP-1? (CMS Bundle) 4 2
The new face of sepsis Nearly 1.5 million cases and 215k deaths each year CDC 2016 33-50% of all inpatient deaths are due to sepsis JAMA. 2014;312(1):90-92 Increasing incidence due to: Aging population Increased use of immunomodulating therapy Longer survival in cancer patients RR sepsis with cancer 9.77 vs. non-cancer patient Increased transplantation 29% of lung transplant patients die from sepsis Chest 2006, 129(6):1432 J Heart Lung Transplant 2005, 24(11):1834 5 Case 65 yo man with a history of HTN, CAD, ischemic cardiomyopathy (EF 45%) admitted with atrial fibrillation from cardiologists office Temp 98.6; HR 133; BP 98/44; RR 22; O2 sat 95% on 2L NC On exam he is somewhat anxious with a rapid, irregular heart rate Is he septic? 6 3
What year is it? 1991 Definitions for Sepsis and Organ Failure and Guidelines for the Use of Innovative Therapies in Sepsis 2001 SCCM/ ESICM/ ACCP/ ATS/ SIS International Sepsis Definitions Conference 2016 The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) 7 1991 - Sepsis 1 Definition SIRS (systemic inflammatory response) Two of following: Temp > 38 or < 36 HR > 90 RR > 20 or PaCO2 < 32 WBC > 12 or < 4 or bands > 10% 8 4
Case 65 yo man with atrial fibrillation Lab studies with WBC of 13,000 Admits to some cough and sputum production Is he septic? 9 Case 65 yo man with atrial fibrillation Lab studies with WBC of 13,000 Admits to some cough and sputum production Is he septic? 10 5
Case Patient also notes he has new lower extremity edema Nursing notes decreased urine output Initial work-up reveals a creatinine of 2.0 (previously 0.9) Now what does he have? 11 2001 12 6
2001 13 2001 - Continuum of Sepsis Sepsis Severe Sepsis Septic Shock Sepsis with 1 sign of organ failure Cardiovascular (refractory hypotension) Renal Respiratory Hepatic Hematologic - coagulopathy CNS - delirium Metabolic acidosis 14 Adapted from: Bone RC, et al. Chest 1992;101:1644 Opal SM, et al. Crit Care Med 2000;28:S81 7
Our Patient Blood cultures grow gram-positive cocci His clinicians carefully exam and order labs to evaluate the 25+ possible clinical findings of the sepsis-2 definition They variously describe him as having: Pneumonia SIRS Sepsis Severe Sepsis Bacteremia Patients family now demands to talk to doctor because they are utterly confused 15 Out with Old (2.0), In with New (3.0) Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. 8
Out with Old (2.0), In with New (3.0) Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. How to Measure Organ Failure? SOFA Increase > 2 18 9
Sepsis New versus Old Definition Old Version (1&2) (don t memorize) Infection = Infection SIRS criteria + Infection = Sepsis Infection + Organ Failure = Severe Sepsis Infection + Shock = Septic Shock New Version (Sepsis-3) (memorize) Infection = Infection SIRS criteria + Infection = Infection Infection + Organ Failure = Sepsis Infection + Shock = Septic Shock 19 Should we admit him? Where? qsofa can identify patients at high risk for death or prolonged ICU stay qsofa is NOT meant to be a screen for sepsis 20 10
What do we need to do for our patient? 21 Why is My Hospital So Interested in This? 22 11
Why is My Hospital So Interested in This? What is CMS definition of Sepsis? Think Severe Sepsis 23 Why is My Hospital So Interested in This? What is CMS definition of Sepsis? Think Severe Sepsis 24 12
Why is My Hospital So Interested in This? What is CMS definition of Sepsis? Think Severe Sepsis 25 Our Patient ABG shows lactate 4.5 mmol/l SBP dips to 70 s Norepinephrine started Antibiotics given Ceftriaxone Azithromycin Now what do we do? 13
What do we need to do for our hospital / CMS? CMS Mandated Targets for Hospitals Measure lactate Obtain cultures prior to antibiotics Administer antibiotics Administer 30ml/kg fluid for hypotension or elevated lactate Apply vasopressors Assess volume status Repeat lactate What do we need to do for our hospital / CMS? CMS Mandated Targets for Hospitals Measure lactate Obtain cultures prior to antibiotics Administer antibiotics Administer 30ml/kg fluid for hypotension or elevated lactate Apply vasopressors Assess volume status Repeat lactate 14
Future Clinicians need to be familiar with both new and old definitions of sepsis Sepsis / Septic Shock (from 2016 definition) Severe Sepsis (from CMS / 2001 definition) Recognition and identification remains the mainstay of improving outcomes and survival Clinicians need to be familiar with both the surviving sepsis guidelines and CMS bundle for sepsis care 29 Thank You 15